<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_patient_char_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_patient_char_id" data-rule="required" data-source="presentation/patient/char/index" class="form-control selectpage form-control" name="row[presentation_patient_char_id]" type="text" value="{$row.presentation_patient_char_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Date_of_birth')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-date_of_birth" class="form-control datetimepicker form-control" data-date-format="YYYY-MM-DD" data-use-current="true"
                   name="row[date_of_birth]" type="text" value="{$row.date_of_birth}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Age_at_time_of_onset_of_reaction_event_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-age_at_time_of_onset_of_reaction_event_number"
                   class="form-control form-control" name="row[age_at_time_of_onset_of_reaction_event_number]" type="number" value="{$row.age_at_time_of_onset_of_reaction_event_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Age_at_time_of_onset_of_reaction_event_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-age_at_time_of_onset_of_reaction_event_unit" class="form-control form-control" name="row[age_at_time_of_onset_of_reaction_event_unit]" type="text" value="{$row.age_at_time_of_onset_of_reaction_event_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Foetus_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-foetus_number" class="form-control form-control" name="row[foetus_number]" type="number" value="{$row.foetus_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Foetus_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-foetus_unit" class="form-control form-control" name="row[foetus_unit]" type="text" value="{$row.foetus_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_age_group_as_per_reporter')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-patient_age_group_as_per_reporter" class="form-control selectpicker" name="row[patient_age_group_as_per_reporter]">
                {foreach name="patientAgeGroupAsPerReporterList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.patient_age_group_as_per_reporter"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
